A Comparative Study of Interventions of Middle Turbinate Medialization in Endoscopic Sinus Surgery

The shape and position of middle turbinate play an important role in ventilation and drainage of the osteomeatal complex. The preservation of middle turbinate is one of the major goals of functional endoscopic sinus surgery (FESS). Middle turbinate intervention is essential to prevent obliteration of osteomeatal complex. The aim of this prospective study is to postulate which middle turbinate intervention is most effective and compare the results with conventional technique. In this randomized controlled study, 60 patients were included of the age group of 15-60 years who presented to the Otorhinolaryngology OPD of our institute between November 2017 to June 2019 with symptoms of chronic sinusitis with clinical and radiological evidence and who underwent FESS. The patients were divided into three group, Group A-Bolgerization (n = 20), Group B-Vicryl-conchopexy (n = 20) and Group C-No intervention, Control group (n = 20). The patency of middle meatus and the status of middle turbinate (medialized or lateralized or neither of the two) was ascertained postoperatively. Improvement in symptoms was also evaluated. The middle turbinate was medialized in 90% of Group A and 95% of Group B cases. The middle turbinate was neither medialized nor lateralized in 70% of patients in Group C. 70% of the patients in Group A and 80% of patients in Group B had complete improvement in symptoms with no recurrence of sinusitis compared to Group C in which only 50% of the patients had improvement in symptoms due to development of synechiae. Medialization of the middle turbinate should be considered as one of the essential steps of FESS as it helps in improving the surgical outcome.

Osteitis in Eosinophilic Chronic Rhinosinusitis

OBJECTIVES

Eosinophilic chronic rhinosinusitis (ECRS) is an allergic inflammatory disease characterized by chronic inflammation of the sinus mucosa, and sometimes, osteitis. This study aimed to investigate the pattern of osteitis in ECRS and the relationship between bony thickening of the middle turbinate and recurrence of ECRS.

METHODS

A total of 246 patients with paranasal diseases were included in the study. The patients' data on bone thickening level, mucosal thickening, polyp score, clinical severity, and laboratory data were retrospectively evaluated.

RESULTS

In total, 38, 186, and 22 patients had ECRS, non-ECRS (NECRS), and odontogenic sinusitis, respectively. The Lund-Mackey (LM) score and Global Osteitis Scoring Scale (GOSS) scores in patients with ECRS were higher than those in patients with other paranasal diseases. There was a significant positive correlation between the GOSS score and ECRS clinical disease severity. Postoperative recurrence was significantly increased in patients with ECRS associated with bony thickening of the middle turbinate.

CONCLUSION

Both mucosal inflammation and osteitis were more severe in patients with ECRS than in patients with other diseases, and clinical disease severity was correlated with osteitis. Furthermore, the postoperative recurrence rate tended to increase in patients with ECRS who had bony thickening of the middle turbinate.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Middle Turbinate Friendly Technique for Cribriform Cerebrospinal Fluid Leak Repair

OBJECTIVE

To compare surgical outcomes between 2 techniques for cribriform cerebrospinal fluid leak (CSF) repair with middle turbinate preservation (MTP) vs middle turbinate resection (MTR). A secondary outcome is to examine the effectiveness of collagen dura matrix (CDM) as a grafting material for repair of isolated cribriform skull base defects.

STUDY DESIGN

A retrospective chart review was performed of consecutive patients who underwent cribriform CSF repair at Emory University over the past 15 years.

SETTING

Tertiary care rhinology practice.

SUBJECTS

Adult patients with cribriform defects limited to the cribriform plate that did not extend lateral to the middle turbinate (MT) and were reconstructed with a free graft (mucosal or synthetic).

METHODS

Patients were stratified into 2 primary groups by surgical technique: MTP vs MTR. A subset of patients underwent repair with CDM alone and was analyzed separately for CSF repair failure rate.

RESULTS

Of 68 patients identified with cribriform defects, 42 underwent repair with MTP and 26 underwent repair with MTR. Average follow-up time was 495 days. Patients with idiopathic intracranial hypertension were also equally distributed (P = .20). Primary CSF leak repair success was 95.6%, with 100% of leaks ultimately repaired. A subset of 39 patients underwent repair with CDM alone, with a primary repair success rate of 94.9%.

CONCLUSIONS

We present an effective method for repair of cribriform CSF leaks while preserving the MT. CDM can be successfully used as a free graft alone for repair of isolated cribriform CSF leaks.

Silastic "Spring" Spacers for Use Following Endoscopic Sinus Surgery

The prevention of middle turbinate lateralization, and middle meatal synechiae formation, is the key to maintain a patent ostiomeatal complex following endoscopic sino-nasal surgery (ESS). Different techniques have been described to prevent this undesirable outcome, however, most of them are invasive, expensive, uncomfortable and/or obstructive. We present our technique to modified silastic sheets to circumvent these problems and improve ventilation and drainage of sinuses after surgery. The aim of this paper is to present how this silastic sheeting can be easily customized to the shape of the ethmoid cavity after ESS, allowing for ventilation of the aerated sinonasal cavities and at the same time preventing problematic synechiae/scar formation. A practical and easy technique to customize silastic stents following ESS is presented. Silastic sheets could be easily customized of the ethmoid cavity after ESS providing an excellent alternative to reduce middle turbinate lateralization and synechiae formation.

Bleeding risk associated with resection of the middle turbinate during functional endoscopic sinus surgery

BACKGROUND

The decision to resect the middle turbinate (MT) during functional endoscopic sinus surgery is controversial. Although there have been a variety of studies that examined the functional outcome related to this maneuver, very few studies evaluated the potential for complications, in particular, epistaxis.

OBJECTIVE

We sought to determine if resection of the MT during functional endoscopic sinus surgery leads to an increased risk for postoperative bleeding.

METHODS

Patients who underwent functional endoscopic sinus surgery for chronic sinusitis or nasal polyposis between 2004 and 2014 at a single institution were analyzed for bleeding and other complications after resection of the MT.

RESULTS

Between 2004 and 2014, 1185 sinus surgeries were performed by 18 surgeons. A propensity matched set of 228 patients who underwent turbinate resection, and 228 controls were selected based on predicted probabilities from a logistic regression that predicted turbinate resection and that was adjusted for age, sex, and procedure. There were 89 patients with bilateral turbinates removed and 139 with unilateral turbinates removed. There was no significant difference in major bleeding or other complication rates between the two groups. Patients who underwent resection of at least one MT were 3.95 times more likely to have minor bleeding compared with those who did not; this risk increased with the number of turbinates resected (trend p = 0.008). Patients on anticoagulation medications were at a significant risk of bleeding if their MT was removed (p = 0.007), whereas patients on aspirin or antiplatelet therapy were not at a significant risk.

CONCLUSION

There was no increased risk of major bleeding or other complication associated with resection of the MT. However, there was a significantly increased minor bleeding rate associated with MT resection, particularly if the patient was on anticoagulants.

Efficacy of syringe-irrigation topical therapy and the influence of the middle turbinate in sinus penetration of solutions

Introduction

Topical therapies are the best postoperative treatment option for chronic rhinosinusitis, especially those with high volume and pressure, such as the squeeze bottles. However, they are not an available option in Brazil, where irrigation syringes are used.

Objective

To investigate the efficacy of topical sinonasal therapy with syringe and the influence of the middle turbinate on this process

Methods

Intervention study in training models (S.I.M.O.N.T.). After standard dissection, three interventions were performed (Nasal Spray 4 puffs, 60-mL syringe and 240-mL Squeeze Bottle) with normal and Sutured Middle Turbinate. Images of each sinus were captured after the interventions, totalizing 144 images. The images were classified by 10 evaluators according to the amount of residual volume from zero to 3, with zero and 1 being considered poor penetration and 2 and 3, good penetration. The 1440 evaluations were used in this study.

Results

Considering all middle turbinate situations, the amount of good penetrations were 8.1% for Spray; 68.3% for Syringe, and 78.3% for Squeeze (p < 0.0001). Considering all types of interventions, the Normal Middle Turbinate group had 48.2% of good penetrations and the Sutured Middle Turbinate, 55% (p = 0.01). Considering only the Sutured Middle Turbinates, there was no difference between the interventions with Syringe and Squeeze (76.3% vs. 80.4%; p = 0.27).

Conclusion

Topical therapy of irrigation with a 60-mL syringe was more effective than that with nasal spray. The status of the middle turbinate proved to be fundamental and influenced topical therapy. Irrigation with syringe was as effective as the squeeze bottle when the middle turbinate was sutured to the nasal septum.

Clinical effects of middle turbinate resection after endoscopic sinus surgery: a systematic review

BACKGROUND

The middle turbinate (MT) is a structure that is often carefully preserved during endoscopic sinus surgery (ESS) in an effort to preserve nasal physiology and serve as an anatomic landmark. However, resection is performed in select cases because of involvement of the MT in the inflammatory process, obstruction, or instability. Therefore, significant controversy exists among surgeons regarding the indications for proceeding with MT resection in ESS. This study evaluates clinical outcomes of MT resection after ESS.

METHODS

An English language search of the PubMed and Ovid databases was conducted for publications examining clinical outcomes of MT resection after ESS performed for chronic rhinosinusitis. Two authors independently examined the articles to identify those meeting inclusion criteria. Any differences over which studies to include were resolved by discussion and consensus. Bias assessment was conducted using the Cochrane Collaboration bias tool for randomized controlled trials and the Newcastle-Ottawa bias tool for cohort and case-control studies.

RESULTS

After initial screening, search results revealed 71 articles that warranted detailed evaluation. After applying inclusion criteria, 9 studies were selected. A total of 2123 patients were included among the studies. All studies were controlled. Within the limited available data, olfaction scores may be improved in the MT resection patients compared with MT preservation patients. No difference between the groups was noted for quality of life outcomes, nasal airway resistance, or rates of postoperative frontal sinusitis. In regard to postoperative endoscopic examinations, some studies note greater improvement in the MT resection group compared with the MT preservation group, while others were equivalent.

CONCLUSION

Although some studies show outcome benefit in MT resection patients compared with MT preservation patients, several others show no difference. When MT resection was appropriately indicated, no studies showed detrimental effects compared with MT preservation in their designated outcomes. Additional more stringent studies are warranted.

Computational fluid dynamics as surgical planning tool: a pilot study on middle turbinate resection

Controversies exist regarding the resection or preservation of the middle turbinate (MT) during functional endoscopic sinus surgery. Any MT resection will perturb nasal airflow and may affect the mucociliary dynamics of the osteomeatal complex. Neither rhinometry nor computed tomography (CT) can adequately quantify nasal airflow pattern changes following surgery. This study explores the feasibility of assessing changes in nasal airflow dynamics following partial MT resection using computational fluid dynamics (CFD) techniques. We retrospectively converted the pre- and postoperative CT scans of a patient who underwent isolated partial MT concha bullosa resection into anatomically accurate three-dimensional numerical nasal models. Pre- and postsurgery nasal airflow simulations showed that the partial MT resection resulted in a shift of regional airflow towards the area of MT removal with a resultant decreased airflow velocity, decreased wall shear stress and increased local air pressure. However, the resection did not strongly affect the overall nasal airflow patterns, flow distributions in other areas of the nose, nor the odorant uptake rate to the olfactory cleft mucosa. Moreover, CFD predicted the patient's failure to perceive an improvement in his unilateral nasal obstruction following surgery. Accordingly, CFD techniques can be used to predict changes in nasal airflow dynamics following partial MT resection. However, the functional implications of this analysis await further clinical studies. Nevertheless, such techniques may potentially provide a quantitative evaluation of surgical effectiveness and may prove useful in preoperatively modeling the effects of surgical interventions.

The effect of radiofrequency turbinoplasty vs two other methods in the management of polypoid changes of the middle turbinate: a randomized trial

BACKGROUND

The aim of this study was to evaluate the effectiveness of middle turbinate radiofrequency (RF) turbinoplasty for the management of the polypoid middle turbinate compared to middle turbinate resection and middle turbinate medialization.

METHODS

The study was performed on 90 patients at a tertiary referral hospital with nasal polyposis resistant to maximal medical treatment. At the time of functional endoscopic sinus surgery (FESS), patients were randomized into 3 groups with respect to the management of the middle turbinate: middle turbinate turbinoplasty by RF; partial resection of the middle turbinate; and medialization of the middle turbinate by scarification to the septum. We evaluated the patients' symptoms according to the 22-item Sino-Nasal Outcome Test (SNOT-22) preoperatively and 1 year after surgery. Additionally, polyp recurrence and complications were compared among the 3 groups.

RESULT

One year after surgery, there was no significant difference in SNOT-22 scores between the groups. However, the RF group had a significantly lower polyp recurrence rate when compared to other groups (p < 0.05).

CONCLUSION

RF middle turbinate turbinoplasty could be considered an alternative to other common approaches, but it needs further long-term studies before widespread usage.

Endoscopic approach to middle turbinate squeeze syndrome

Middle turbinate squeeze syndrome (MTSS) refers to sino-nasal headache due to intense contact between the middle turbinate and the nasal septum and/or between middle turbinate and other structures in the lateral nasal wall. This study was intended to evaluate the efficacy of precise endoscopic surgical treatment of MTSS. This is a prospective study of 126 patients with refractory cephalgia due to endoscopically confirmed MTSS who underwent functional endoscopic naso-sinus surgery (FENS) wherein the contact points and ostio-meatal complex obstruction were endoscopically relieved. 91% of cases reported improvement/resolution of headache and 95% of cases had relieved contact points as documented endoscopically. This surgery was also found to facilitate resolution of sinus disease, both radiologically (in 64% of cases) and endoscopically (in 94% of cases). Cephalgia caused by MTSS can be effectively treated by an ultra-conservative endoscopic approach.

Endoscopic turbinoplasty of concha bullosa: long term results

The aim of this study is to assess the long-term results of our endoscopic turbinoplasty technique for concha bullosa. Thirty-six patients of chronic or recurrent sinusitis who had concha bullosa on CT scan along with mucosal disease in sinuses and underwent turbinoplasty with functional endoscopic sinus surgery were studied. They were followed regularly with endoscopic examination for 7 years and were assessed for immediate or longterm complications of the procedure. Results of 36 patients revealed bilateral concha bullosa in 16 (44.4%) and unilateral concha bullosa in 20 (55.6%) patients. Out of 52 sides of turbinoplasties which were followed for average of 89 months, only 3 sides (5.76%) had synechia between middle turbinate and septum. Only 1 (1.92%) side had adhesions between lateral wall and middle turbinate. There were no other immediate or longterm complications. We conclude from our study that endoscopic turbinoplasty is safe and effective procedure for concha bullosa. It preserves middle turbinate anatomically and physiologically and treats the concha with negligible complications.

What is the role of partial middle turbinectomy in endocanalicular laser-assisted endonasal dacryocystorhinostomy?

BACKGROUND

This study was designed to compare outcomes of endocanalicular laser-assisted endonasal dacryocystorhinostomy (DCR) with and without partial anterior middle turbinectomy.

METHODS

A prospective randomized comparative study was conducted on 91 subjects with primary acquired nasolacrimal duct obstruction, undergoing endocanalicular (ECL) procedures. Group 1 was composed of 44 (7 bilateral) patients undergoing ECL diode laser-assisted endonasal DCR without partial anterior middle turbinectomy and group 2 was composed of 47 (7 bilateral) patients undergoing partial anterior middle turbinectomy and ECL diode laser-assisted endonasal DCR. Follow-up period was 11.0 (6.0-14.5 months) months for group 1 and 9.2 (5.0-14.2 months) months for group 2. Functional success was defined as absence of epiphora and anatomic success was defined as ability to irrigate the lacrimal system. Anatomic and functional success at the 1st week, 3rd month, and final postoperative examinations of two groups were compared using chi-square tests.

RESULTS

Final anatomic successes were 39/51 (76%) cases for group 1 and 51/54 (94%) cases for group 2. Final functional successes were 36/51 (%71) patients in group 1 and 48/54 (88%) patients in group 2. Group 2 had higher success at the final examination and the difference was statistically significant.

CONCLUSION

We recommend partial anterior middle turbinectomy in all laser ECL laser-assisted endonasal DCR, but further studies with larger sample sizes are needed to strengthen our hypothesis.

Middle turbinectomy for exposure in endoscopic endonasal transsphenoidal surgery: when is it necessary?

OBJECTIVES

To evaluate the benefits of middle turbinectomy on the exposure of the skull base structures.

DESIGN

An anatomical study on 20 fresh cadaver heads.

METHODS

The extent of the exposure of the skull base structures during endoscopic endonasal approach has not been addressed specifically in respect to the whether or not the middle turbinectomy is performed. We compared the extent of exposure obtained by endonasal transsphenoidal approaches without middle turbinectomy (NMT), with unilateral turbinectomy (UMT), and with bilateral turbinectomy (BMT). Our preselected target points in the skull base consisted of sella turcica, tuberculum sella, planum sphenoidale, clivus (upper and middle third), and ipsilateral sphenopalatine artery (SPA).

RESULTS

Of our preselected anatomic target points, only the middle third of the clivus and ipsilateral SPA had enhanced exposure in UMT (100% for both structures) compared to NMT (45% and 20%, respectively). The addition of a BMT did not provide added exposure to any target compared with a UMT.

CONCLUSIONS

Middle turbinectomy may not be necessary for endonasal transsphenoidal approach to the lesions of the sella, planum sphenoidale, and upper third of the clivus. However, gaining access to the middle clival region is facilitated by resection of middle turbinate.

Outcomes after middle turbinate resection: revisiting a controversial topic

OBJECTIVES/HYPOTHESIS

To evaluate differences in endoscopy exam, olfactory function, and quality-of-life (QOL) status after endoscopic sinus surgery (ESS) for patients with and without bilateral middle turbinate (BMT) resection.

STUDY DESIGN

Open, prospective, multi-institutional cohort.

METHODS

Subjects completing enrollment interviews, computed tomography (CT), and endoscopy exam were asked to provide pre- and postoperative responses to the Smell Identification Test (SIT), Rhinosinusitis Disability Index (RSDI), Chronic Sinusitis Survey (CSS), and the Medical Outcomes Study Short Form-36 Health Survey (SF-36). Bivariate and multivariate analyses were performed at the .05 alpha level.

RESULTS

Forty-seven subjects with BMT resection were compared to 195 subjects without BMT resection with a mean follow-up of 17.4 months postoperatively. Patients with BMT resection were more likely to have asthma (P = .001), aspirin intolerance (P = .022), nasal polyposis (P = .025), and prior sinus surgery (P = .002). Patients with BMT resection had significantly higher baseline disease burden measured by endoscopy, CT, and SIT scores (P < .001). No significant differences in improvement were found in RSDI, CSS, or SF-36 scores between patients with BMT resection and those with BMT preservation (P > .05). Patients undergoing BMT resection were more likely to show improvements in mean endoscopy (-4.5 +/- 5.2 vs. -1.9 +/- 4.3; P = .005) and olfaction (5.3 +/- 10.8 vs. 1.3 +/- 7.6, P = .045) compared to those with BMT preservation.

CONCLUSIONS

This investigation found no difference in QOL outcomes in patients with BMT preservation vs. resection. Patients undergoing BMT resection did, however, show greater improvements in endoscopy and SIT scores, which persisted after controlling for confounding factors.